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NQU * I <br /># <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />qC%F0 <br />Facility Name:, <br />SW <br />Inspection Date: <br />Facility Address: <br />41 <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufactuffir Training: <br />II <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />Leak detector <br />El <br />El mechanical Model: <br />Spill bucket 0 minimum 5 gallon <br />0 electronic Serial #: <br />0 1 hour hydrostatic 0 Incon TS -STS <br />0 line test programmed <br />El Caldwell System El Other <br />Leak detector <br />❑ <br />El mechanical Model: <br />0 1 hour hydrostatic El Incon TS -STS <br />0 electronic Serial #: <br />0 Caldwell System 0 Other <br />0 line test programmed <br />Primary piping testing at: <br />Leak detector <br />E] <br />El mechanical Model: <br />minutes <br />0 electronic Serial #: <br />Secondary containment testing for: <br />0 line test programmed <br />UDC(s) Piping <br />sensor <br />El <br />El positive shutdown Model: <br />Testing for the above components are next due by: <br />0 fail safe Serial #: <br />Note: Please be aware that 2* containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />DNA <br />Cold start of monitoring panel <br />sensor <br />Corrosion protection <br />0 positive shutdown Model: <br />I Other: see below <br />0 fail safe Serial #: <br />0 NA <br />sensor <br />El <br />0 positive shutdown Model: <br />• fail safe Serial #: <br />• NA <br />El <br />Drop tube with mechanical overfill at 95% <br />El <br />_ Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) —j <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />El El 1 hour hydrostatic 0 Incon TS -STS <br />El Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic 0 Incon TS -STS <br />Re <br />El Caldwell System El Other <br />Spill bucket 0 minimum 5 gallon <br />El <br />0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2* containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />El <br />Corrosion protection <br />El <br />I Other: see below <br />W awl <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT Ell CURRENT HOURLY RATE. <br />EHD 21n pet• <br />Re <br />Ei 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />Rev 11/17//08 <br />